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t't;tYtt'kt tt tt tY ktt kY ktMkt:tt tt'tt tt k;'tfi tt tt kt tt tt kYttAyff <br /> e APPLICATION FOR PIRMIT k SAN JOAQUIN LOCAL HEALTH DISTRICTk: <br /> k: UIDBRGROUND TANK t: 1601 B HIIELTON ATB., STOCKTON CAI <br /> r CLOSURE OR IIINDONMBYT k: Telephone 1209) 668-3120 t: <br /> "I:ki:ffel:ti:Nf ttm kt:ti:ttt'tt'ti:ft kXtvti:ti:ti:kt:tk kt:Ky kt:tt.it:kyft11:kt:kykt0: <br /> APPLICATION FOR PBRMANKRT/TRMPORIRT CLOSURE OR ABAIDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCES STORIGE FACILITY <br /> THIS PEIMII EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT 11118 IN 111 SHADED AREAS. INDICATE PERMIT TYPE IBLOY: <br /> X RRMOVAL TEMPORARY CLOSURE —_ ABANDONNINT IN PLACE <br /> BPA SITE I CAC-000167373 PROJECT CONTACT 6 TELEPHONE I 1-869-2889 <br /> F FACILITY NAME Mr.&Mrs . Wayne Pyburn PdONE 1 1-869-2889 <br /> C ADDRESS 20851 So. Sutluff Rd. Escalon, Ca. 95320 <br /> L CROSS STREET <br /> I ---- 1 -869-2889 <br /> T OYXSR/OPBRITOfl Mr. Wayne Pyb� -PdON6 1 =_°-_-- <br /> 1 <br /> C CONTRACTOR NAME PHONE 1 If <br /> 0 _ q. ---. 209 464-8333 <br /> I COYTIICTOR IDDIRSS 820 No. Union St. C1 LIC 1 309105 CLASS C-61 ,SA <br /> T ---- -- -_— -- WC 80161762 RA2 <br /> I INSURER TRANS. AMERICA INS.SERVICES YORK.COMp.I <br /> C FIRS DISTRICT C_ 1 2c- r PERMIT I/INSPTR <br /> T --- <br /> 0 LABORATORY NAME Calif. Water Lab. PHONE IU�1/ S� _ �/o.>Zj <br /> R ---- - ( --- — — - <br /> SIMPLING FIRM' 1SAMPLING METIOD <br /> — XpKC!®NINNO�RYNIIkNRBR119�INImAIR�NN1 - ------_—� <br /> TANK ID I TIKE SITE CHEMICALS S10RID CURRENTLI CHEMICALS STORED PRSVIOUSL <br /> T 1 - 550 Gal. Reg. Gas <br /> 1 19- 232_- 2L_ --- ---------- <br /> K 31- <br /> 79-_-- — —_ <br /> -- — LIST ADDITIONAL TANK INF03HITION AS WEEDSD ON SEPARATE FOIN <br /> INNIOpNtlI 'NtNNRWIRNIRNRIIYgRNIYYYNYRIIXIKbNIRYYIII. RYIMI!�IIYYYINRgRNIIIflRNId!NflIkNYRINNi!YWAINXRIYIWYYWLIpN!'JIYOHflMIIflIIItlYYUMdNJIYINiNi!IYBkIYYIIIN9tl!YIIYXNIIOIIYIYYIRIIXIIIItlIHINIUWWMYIINIIYIYUXIIIIIIYNNXRNU <br /> P APPROVED IP ., WITH CONDITIONS DISAPPROVED <br /> L (SHE ITTACHMEIT 1TH C YO[?IONS) <br /> I PLAN RRVIEYBRS NIMB —_ _ --CC.ir1^P --^_--__DATE_ <br /> tl -- <br /> NYNNNYNRIN6NXNNNIX <br /> APPLICANT MUST PERFORM ALL RORK 1 ACCORDINCE WITH SAN JOIDUIN COUNTY ORDINANCES, S11T6 LIVS, AND RULES AND REGULATIONS <br /> OF THE $IN JOAQUIN LOCAL HEALTH DISTRICT, OWNER 09 LICENSED AGENT'S SIGNATURE CERTIFIES THB FOLLOVIIG: 11 CERTIFY THAT <br /> IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SMALL NOT EMPLOY ANY PERSON IN SUCH MANNER AS TO BECOM <br /> SUBJECT TO WORKER'S COMPENSATION LIVS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE <br /> FOLLOVIIG: It CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 13 ISSUED, 1 SHALL EMPLOY PERSONS SUBJEC <br /> TO YORKER'S COMPENSITION LAWS OF CALIFORNIA. <br /> CALL FOR INSPECTIONS AT LEAST 40 HOURS IN ADVANCE <br /> SIGNED-- --------- ----- --------DATE_------- ----- <br /> OFFICE USE ONLY-40 23 016 12/81 <br /> SSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSS <br /> SWEEPS 1-I-COMP—I I60C CODE] CODE AMOUNT DUB_I AMOUNT RCVD L. CKI/CASH-I- RCVD-BT --I DATE-RCVD-_I PERMIT I <br />' J 11 IL JI 1I jl <br />